2019 Nurses Application

Please completely fill-out this application to assist us in reviewing your Nurse Application.

Applications cannot be accepted until fully completed.

After submitting this application, you will be contacted by the Head Nurse who will notify you regarding the status of your application.

If anything regarding the information you provided between now and the start of camp changes, please contact headnurse@campcasey.org so we can have the most up-to-date information.

Last minute cancellations cause great hardship for camp leadership and places increased risk management concern for our campers.
Have you volunteered for Kiwanis Camp Casey Before?*
- Yes
- No
Are you associated with another Kiwanis Club?*
- Yes
- No
What other Kiwanis Club are you associated with?*
What organization or person, if any, referred you to Camp Casey?
Contact Infomation
Name*
First Last
Date of Birth*
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone (home)*
Phone (work)
Phone (cell)
Emergency Contact
Name*
First Last Relation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Alternate Phone
Email
In the event of a medical emergency, what information will an EMT or medical personal attending to your care need to know?
Nursing Information
Are you a current nursing student?*
- Yes
- No
What school are you attending?*
How many years of nursing experience do you have?*
Nursing License information:*
Name as Appears on License License/Credential Number State of Licensure
Do you have a secondary Nursing License to list?*
- Yes
- No
Secondary Nursing License information:*
Name as Appears on License License/Credential Number State of Licensure
Please list certifications you hold, with their expiration dates:*
Do you have personal nurse liability insurance?*
Personal nurse liability insurance is required to volunteer at camp, we will assist you in signing up and will reimburse you for the cost.
- Yes
- No
What company do you hold your policy through?*
When does this policy expire?*
Employment Information
Current Employer:*
Position/Area of Nursing:*
Start Date:*
Duties and Responsibilities:*
Do you have any experience working with children or adults with special needs?*
- Yes
- No
Please write about your experience:*
School Information
College/University Program:*
School Location:*
City State / Province / Region
Degree Expected to Earn:*
Expected Date of Graduation:*
Do you have a Nursing Advisor?*
- Yes
- No
Nursing Advisor Name:*
Nursing Advisor Phone
Nursing Advisor Email*
Time at Camp
Camp dates are Sunday, July 28th through Saturday, August 3rd.

Please let us know when you plan on arriving and leaving camp.

Note any volunteer who is staying multiple days must be willing to consider a “high” need role such as fire watch, counselor night off or mess hall floors .
Will you be able to attend the Camp Casey Annual picnic on May 18th?*
- Yes
- No
Desired Days to Volunteer*
Please check all the days you will volunteer:
- Sunday - July 28th, 2019
- Monday - July 29th, 2019
- Tuesday - July 30th, 2019
- Wednesday - July 31st, 2019
- Thursday - August 1st, 2019
- Friday - August 2nd, 2019
- Saturday - August 3rd, 2019
Please tell us your arrival day*
- Sunday - July 28th, 2019
- Monday - July 29th, 2019
- Tuesday - July 30th, 2019
- Wednesday - July 31st, 2019
- Thursday - August 1st, 2019
- Friday - August 2nd, 2019
- Saturday - August 3rd, 2019
Please estimate your intended arrival time.*
- Between 6:00 am to 10:00 am
- Between 10:00 am to 2:00 pm
- Between 2:00 pm to 6:00 pm
- Between 6:00 pm to 10:00 pm
- Between 10:00 pm to 6:00 am (following day)
Please tell us your departure day*
- Monday - July 29, 2019
- Tuesday - July 30, 2019
- Wednesday - July 31, 2019
- Thursday - August 1, 2019
- Friday - August 2, 2019
- Saturday - August 3rd, 2019
Please estimate your intended departure time.*
- Between 6:00 am to 10:00 am
- Between 10:00 am to 2:00 pm
- Between 2:00 pm to 6:00 pm
- Between 6:00 pm to 10:00 pm
- Between 10:00 pm to 6:00 am (following day)
Will you need housing while volunteering at camp?*
- Yes
- No
Are you willing to share a room with anyone?*
- Yes
- No
Is there a particular person you'd like to share a room with?
Provide any additional comments or information.
Please let us know if there is anything else we need to know about the availability of your volunteer time.
Dietary Information:*
- Gluten Intolerant
- Lactose Intolerant
- Vegetarian
- No Food Restrictions
Note: The Camp Casey kitchen staff will do their best to accommodate common food allergies. However, given the complexity and procedures for vegan diets the kitchen staff will not be able to provide vegan meals. Sorry for the inconvenience.
Camp Casey T-Shirts
Please provide us with your t-shirt size so we an provide you a t-shirt.
- Small
- Medium
- Large
- X-Large
- XX-Large
- XXX-Large
Acknowledgement
Please read and agree to the forms below.
Please read Camp Casey Counselor Volunteer Code of Conduct.*
- I have reviewed the Counselor Volunteer Code of Conduct. I know what is expected and agree to the guidelines specified.
Please read Camp Casey Counselor Volunteer Release Form.*
- I have reviewed the Volunteer Release Form. I know what is expected and agree to the guidelines specified.

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Contact Infomation

Emergency Contact

Nursing Information

Employment Information

School Information

Time at Camp

Acknowledgement